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Online EHDI Case 3 (Part 1 With Answers)

Online EHDI Case 3: A Baby with Persisitent Middle Ear Effusion

Part 1

History: Maria Cortez is a 7½-month old child who is new to your practice. She is the youngest of three children. Her older brothers and her father speak Spanish and English. Mrs. Cortez communicates exclusively in Spanish. Both parents come to this visit and Mr. Cortez serves as translator for Mrs. Cortez. 

You learn that Maria was 8 pound 15 ounces at birth. The pregnancy, labor, and delivery were normal. Prior to discharge from the hospital, the family was told that Maria did not pass her newborn hearing screening. As per the instructions, the family went to their primary care physician when Maria was 2 weeks old for a well child visit and follow-up of her hearing screening. The primary care physician found fluid in the middle ear and referred the child to an otolaryngologist (ENT). 

According to the parents, they were able to get into see the ENT doctor when Maria was one month old. He corroborated the presence of fluid, prescribed 10 days of antibiotics, and scheduled a return visit for 6 weeks later.

Maria was 2½ months of age at the return visit. The ENT doctor again found middle ear fluid. He decided to wait another 6 weeks to see if the effusion cleared. The family returned to the primary care physician when Maria was 4 months of age for a well child care visit. He again saw middle ear effusion, treated the infant with antibiotics, and scheduled her for a return visit at 6 months of age. The family then moved. They are now interested in establishing another primary care physician for Maria.

Mrs. Cortez is very worried about Maria. She fears the child is deaf or has a serious underlying condition that causes the persistent middle ear effusion. She acknowledges that the child is well developed, well nourished, sitting without support, smiling at her parents and fearful of strangers. She does some reciprocal cooing.

On today’s examination, you find evidence of middle ear effusion again and a tympanogram is flat.

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1. What is your impression about Maria?

• The protocol for Universal Newborn Hearing screening has not been followed in this case. Maria is almost 8 months of age and has not had a definitive diagnostic test, which should have occurred before 3 months of age. [UNHS flow sheet]
• Ideally, otoacoustic emissions (OAE) and auditory brain stem responses (ABR) are completed when a child is free from middle ear fluid. However, this ideal situation is not always possible.
    o Maria was initially sent to an otolaryngologist, rather than to an audiologist. The ENT focused on the medical issues but did not assess hearing function.
    o At this time it is imperative to learn the status of her hearing. Refer Maria to an audiologist.

2. How does middle ear effusion impact hearing?

• Middle ear effusion may be associated with conductive hearing loss.
[http://www.asha.org/public/hearing/disorders/types.htm]
• In the case of otitis media, conductive loss is typically mild (10-15 dB) and transient.
• However, conductive hearing loss can arise for other reasons, such as abnormalities of the bones of the middle ear or other structural problems. In such cases the hearing loss may be permanent and moderate to severe.

3. What is your impression about the family?

• Cultural competence requires knowing common patterns of belief or behavior in different ethnic, racial, religious, or language groups. However, it also requires consideration of the unique features of every individual family.
[http://gucchd.georgetown.edu/nccc/
• Families of Hispanic origin are often described as extremely emotive in clinical encounters.
• In this case, this family is understandably upset about the delays in definitive testing. Their style of responding is not the central issue.
• It is important to acknowledge their emotions and support them through this trying period. A challenge in doing this is that you must use Mr. Cortez as a translator for his wife. If you want to communicate specifically with her, using him as a translator, then make eye contact with her while you speak and her husband translates.

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